lipid-lowering treatment in primary prevention

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Before starting statin treatment perform baseline blood tests and clinical assessment, and treat comorbidities and secondary causes of dyslipidaemia. Include all of the following in the assessment:

smoking status
alcohol consumption
blood pressure
body mass index or other measure of obesity
total cholesterol, non-HDL cholesterol, HDL cholesterol and triglycerides
HbA1c
renal function and eGFR
transaminase level (alanine aminotransferase or aspartate aminotransferase)
thyroid-stimulating hormone

Full formal risk assessment

use the QRISK2 risk assessment tool to assess CVD risk for the primary prevention of CVD in people up to and including age 84 years
do not use a risk assessment tool to assess CVD risk in people with type 1 diabetes
use the QRISK2 risk assessment tool to assess CVD risk in people with type 2 diabetes
do not use a risk assessment tool to assess CVD risk in people with an estimated glomerular filtration rate (eGFR) less than 60 ml/min/1.73 m2 and/or albuminuria
- these people are at increased risk of CVD
do not use a risk assessment tool for people with pre-existing CVD
do not use a risk assessment tool for people who are at high risk of developing CVD because of familial hypercholesterolaemia
when using the risk score to inform drug treatment decisions, particularly if it is near to the threshold for treatment, take into account other factors that:
- may predispose the person to premature CVD and
- may not be included in calculated risk scores
recognise that standard CVD risk scores will underestimate risk in people who have additional risk because of underlying medical conditions or treatments. These groups include:
- people treated for HIV
- people with serious mental health problems
- people taking medicines that can cause dyslipidaemia such as antipsychotic medication, corticosteroids or immunosuppressant drugs
- people with autoimmune disorders such as systemic lupus erythematosus, and other systemic inflammatory disorders
recognise that CVD risk will be underestimated in people who are already taking antihypertensive or lipid modification therapy, or who have recently stopped smoking. Use clinical judgement to decide on further treatment of risk factors in people who are below the CVD risk threshold for treatment
severe obesity (body mass index greater than 40 kg/m2) increases CVD risk. Take this into account when using risk scores to inform treatment decisions in this group
consider people aged 85 or older to be at increased risk of CVD because of age alone, particularly people who smoke or have raised blood pressure

Lipid modification therapy for the primary and secondary prevention of CVD

before starting lipid modification therapy for the primary prevention of CVD, take at least 1 lipid sample to measure a full lipid profile
- should include measurement of total cholesterol, high-density lipoprotein (HDL) cholesterol, non-HDL cholesterol, and triglyceride concentrations (fasting sample is not required)
atorvastatin 20 mg should be offered for the primary prevention of CVD to people who have a 10% or greater 10-year risk of developing CVD. Estimate the level of risk using the QRISK2 assessment tool
if a person has CVD then start statin treatment in people with CVD with atorvastatin 80 mg . A lower dose of atorvastatin if any of the following apply:
- potential drug interactions
- high risk of adverse effects
- patient preference

Target cholesterol level

measure total cholesterol, HDL cholesterol and non-HDL cholesterol in all people who have been started on high-intensity statin treatment at 3 months of treatment and aim for a greater than 40% reduction in non-HDL cholesterol. If a greater than 40% reduction in non-HDL cholesterol is not achieved:
- discuss adherence and timing of dose
- optimise adherence to diet and lifestyle measures
- consider increasing dose if started on less than atorvastatin 80 mg and the person is judged to be at higher risk because of comorbidities, risk score or using clinical judgement

Targets from European guidance (2):

The European guideline considers patients in terms of different levels of risk and targets reflect the different level of risk. The guidance states that '..in general, total plasma cholesterol should be <5 mmol/L (<190 mg/dL), and LDL cholesterol should be <3 mmol/L (<115 mg/dL). In subjects with higher CVD risk, the treatment goals should be lower

Level of Risk	Factors putting in this risk category	Lipid lowering target
Very high risk	Subjects with any of the following: documented CVD by invasive or non-invasive testing (such as coronary angiography, nuclear imaging, stress echocardiography, carotid plaque on ultrasound), previous myocardial infarction, ACS, coronary revascularization (PCI, CABG), and other arterial revascularization procedures, ischaemic stroke, peripheral artery disease (PAD) diabetes mellitus (type 1 or type 2) with one or more CV risk factors and/or target organ damage (such as microalbuminuria: 30-300 mg/24 h) severe chronic kidney disease (CKD) (GFR <30 mL/min/ 1.73 m2). a calculated SCORE .>= 10% (of fatal CVD event in next 10 years)	LDL cholesterol goal is <1.8 mmol/L (less than 70 mg/dL) or a >=50% LDL cholesterol reduction when the target level cannot be reached.
High risk	Subjects with any of the following: markedly elevated single risk factors such as familial dyslipidaemias and severe hypertension iabetes mellitus (type 1 or type 2) but without CV risk factors or target organ damage moderate chronic kidney disease (GFR 30-59 mL/min/1.73 m2). calculated SCORE of >= 5% and <10% for 10-year risk of fatal CVD.	LDL cholesterol goal ,2.5 mmol/L (less than 100 mg/dL) should be considered
Moderate risk	Subjects are considered to be at moderate risk when their SCORE is >1 and <5% at 10 years. Many middle-aged subjects belong to this category. Risk may also be higher than indicated in the charts*	LDL cholesterol goal <3.0 mmol/L (less than 115 mg/dL) should be considered
Low Risk	The low-risk category applies to individuals with a SCORE <1% and free of qualifiers that would put them at moderate risk.	no target

SCORE risk chart used in this guideline are not equivalent to QRISK2 as SCORE risk is based on the risk of a FATAL CVD event in the next 10 years. For more information about the SCORE charts then click here

*Risk may also be higher than indicated in the charts in:

sedentary subjects and those with central obesity; these characteristics determine many of the other aspects of risk listed below. The increased risk associated with overweight is greater in younger subjects than in older subjects
socially deprived individuals and those from ethnic minorities.
individuals with diabetes: SCORE charts should be used only in those with type 1 diabetes without target organ damage. Risk rises with increasing blood sugar concentration before overt diabetes occurs
individuals with low HDL cholesterol, increased triglycerides, fibrinogen, apolipoprotein B (apoB), and lipoprotein(a) [Lp(a)] levels, especially in combination with familial hypercholesterolaemia, and perhaps increased high-sensitivity CRP (hsCRP). In particular, a low HDL level will indicate a higher level of risk in both sexes, all age groups, and at all levels of ris
asymptomatic individuals with preclinical evidence of atherosclerosis, for example plaque on carotid ultrasonography
those with moderate to severe chronic kidney disease [glomerular filtration rate (GFR) <60 mL/min/1.73 m2]
positive family history of premature CVD.

Fibrates for preventing CVD

Do not routinely offer fibrates for the prevention of CVD to any of the following:
- people who are being treated for primary prevention
- people who are being treated for secondary prevention
- people with CKD
- people with type 1 diabetes
- people with type 2 diabetes

Nicotinic acid for preventing CVD

do not offer nicotinic acid (niacin) for the prevention of CVD to any of the following:
- people who are being treated for primary prevention
- people who are being treated for secondary prevention
- people with CKD
- people with type 1 diabetes
- people with type 2 diabetes

Bile acid sequestrants (anion exchange resins) for preventing CVD

doo not offer a bile acid sequestrant (anion exchange resin) for the prevention of CVD to any of the following:
- people who are being treated for primary prevention
- people who are being treated for secondary prevention
- people with CKD
- people with type 1 diabetes
- people with type 2 diabetes

Omega-3 fatty acid preparations for preventing CVD

doo not offer omega-3 fatty acid compounds for the prevention of CVD to any of the following:
- people who are being treated for primary prevention
- people who are being treated for secondary prevention
- people with CKD
- people with type 1 diabetes
- people with type 2 diabetes

Combination therapy for preventing CVD

do not offer the combination of a bile acid sequestrant (anion exchange resin), fibrate, nicotinic acid or omega-3 fatty acid compound with a statin for the primary or secondary prevention of CVD

ezetimibe

prescribe in line with NICE guidance - see linked item

Reference:

Last reviewed 01/2018

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lipid-lowering treatment in primary prevention